Peer Reviewed

Photoclinic

A Case of Melanoma

Volume 61 - Issue 1 - January 2021

AUTHORS:
Ryan Short, MSN, FNP-BC1,2 • Candice Short, DNP, FNP-C3

AFFILIATIONS:
1Alleghany Health Services, Sparta, North Carolina
2Hugh Chatham Family Medicine, Independence, Virginia
3East Tennessee State University, Johnson City, Tennessee

CITATION:
Short R, Short C. A case of melanoma. Consultant. 2021;61(1):24-25. doi:10.25270/con.2020.08.00004

Received May 25, 2020. Accepted July 28, 2020.

DISCLOSURES:
The authors report no relevant financial relationships.

CORRESPONDENCE:
Ryan Short, MSN, FNP-BC, 12 Willis St, Ste A, Sparta, NC 28675 (rshort@amhsparta.org)

 

A 38-year-old White man presented to a dermatologist for evaluation of a suspicious lesion on the right side of his nose.

History. The patient reported that he had been at a cookout when a family member had asked about the mole on his nose. The patient stated that he thought that the lesion had always been there but could not say for certain. The patient stated that he had not noticed a change in the lesion; however, he had not been monitoring it for change. He denied pruritus, bleeding, or erythema of the lesion. He reported no family history of skin cancer or other skin disease. The patient’s occupation required him to work outdoors at times. He denied consistent sunscreen use while outdoors.

Physical examination. Upon evaluation, the patient was noted to have a singular, irregularly shaped lesion on the right dorsum nasi, brown and black in color, and approximately 4 mm in size at the largest diameter (Figure).

Lesion on side of patient's nose

Figure. A singular, irregularly shaped lesion was present on the patient’s right dorsum nasi, brown and black in color, approximately 4 mm in size at the largest diameter.

Based on the physical examination findings and the location of the suspicious lesion, the patient was referred to an on-site surgeon for biopsy. The biopsy revealed a diagnosis of melanoma, and a local excision was performed. A second biopsy was completed, which revealed unclean margins, and a repeated excision was performed. At this time, the surgeon went as close to the eye socket as possible. A third biopsy revealed clean margins. A sentinel lymph node biopsy was not performed. The patient did not undergo any adjuvant therapy such as radiation therapy or immune therapy.

Discussion. Melanoma is a form of skin cancer that begins in the melanocytes, found in the basal layer of the epidermis, which produce melanin.1 Melanin determines the pigmentation of the skin.1 Mutations occur in the DNA and are thought to be due to UV radiation exposure. These mutations cause the melanocytes to reproduce uncontrollably in the skin, leading to the development of melanoma.2

Melanoma is the least common skin cancer, comprising 1% of skin cancer diagnoses in the United States; however, it is the deadliest.3,4 If early detection occurs, the 5-year survival rate is 99%, which relates early diagnosis and intervention to improved patient outcomes.5 If the lymph nodes are involved, the 5-year survival rate falls to 65%, and if metastasis occurs, the survival rate drops to 25%.5

White persons are 20 times more likely than African American persons to be diagnosed with melanoma due to lighter skin pigmentation; however, African American persons are more likely to have severe illness due to delayed discovery.6 Statistics show a 2.6% risk of melanoma in the White population, 0.6% in the Hispanic population, and 0.1% in the African American population.4

In the United States, melanoma is the fifth most common cancer in men and the seventh most common cancer in women.7 The average age of diagnosis is 65 years, making increased age a risk factor.4 Other risk factors for melanoma include a personal history of skin cancer, actinic keratosis, ongoing immunocompromise, a family history of melanoma, light-colored skin, blond or red hair, greater than 40 moles, greater than 2 atypical moles, freckles or severely sun-damaged skin, and UV radiation overexposure.7

There are 5 stages and 4 major subtypes of melanoma. Stage 0 is in situ melanoma; stages I and II are localized invasive disease; stage III is regional nodal disease; and stage IV is distant metastatic disease.8 The 4 major subtypes of melanoma are superficial spreading (most common), nodular melanoma (worst outcome), lentigo maligna (best outcome), and acral lentiginous (most common in African Americans and most likely to occur on the soles of feet and palms of hands).2

Differential diagnosis. Several other lesions may mimic melanoma and include melanocytic nevus, benign nevus, lentigo, pigmented basal cell carcinoma, pigmented actinic keratosis, and seborrheic keratosis.9 If melanoma is suspected, a biopsy must be performed to conclude a definitive diagnosis.9

Diagnosis and treatment. Diagnosis includes physical examination and biopsy of the suspicious lesion.1 During a physical examination, the provider should assess the patient’s entire body for suspicious lesions (total body skin examination), specifically looking at suspicious lesions for the ABCDEs: A for asymmetry, B for border, C for color (variation), D for diameter (greater than 5 mm), and E for evolving/erythema.2,5 Melanoma found in early stages usually requires only excision, as seen in this patient’s case. If metastasis has occurred, additional treatments may include lymph node removal, immunotherapy, targeted therapy, radiation therapy and/or chemotherapy.10 Even with experienced dermatologists, the sensitivity of diagnosis is approximately 70%.9

Prevention and early detection. The most important warning sign for melanoma is a new lesion on the skin or a lesion that is changing in size, shape, and color. Other warning signs includes a change in the sensation or surface of a nevus, redness or swelling beyond the border of the lesion, a lesion that does not heal, and pigment that spreads past the border of the nevus.5

Patients need to be educated about skin cancer prevention. Patient education should include avoiding midday sun, wearing sunscreen with a minimum of 30 SPF, wearing protective clothing, avoiding tanning beds, performing skin checks, and becoming familiar with their skin.11 It is important to teach patients to use the body mole map to detect and diagnose skin changes quickly.12 Providers should also educate patients about the “ugly duckling sign,” which is when a lesion is obviously different from other lesions on the body.5,9

Patient education on skin cancer prevention is crucial, especially during the current COVID-19 pandemic. Patients have had to cancel appointments, which can lead to increased anxiety about concerning lesions.13 Telemedicine is an effective tool in bridging the gap during these unprecedented times and, if offered, should help to lessen patient anxiety over suspicious lesions.13 It is important for providers who are active in skin examinations to inform patients about the capabilities of telemedicine in order to reduce delays in diagnosis and treatment of skin cancers, especially melanoma.

It has been well documented that early detection of melanoma skin cancer leads to reduced mortality and improved patient outcomes.7,14,15 Controversy does exist about skin cancer screening guidelines. For example, the US Preventive Services Task Force (USPSTF) has concluded that “a clear statement cannot be made about the benefit of skin cancer screening for melanoma mortality.”16 The USPSTF does recommend screening for high-risk patients.7 While it is important to consider the guidelines, providers should take the time to complete opportunistic skin examinations. If this patient’s melanoma diagnosis and treatment had been delayed 6 more months, he could have had a different outcome, given that the melanoma was very close to the eye socket and brain.

Outcome of the case. The patient experienced no complications after surgical excision. He was expected to make a full recovery and have minimal scarring. The patient was educated to conduct skin self-examinations, to use sunscreen when outdoors, and to undergo a total body skin examination by a provider at least annually.

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